The quality control in pancreatic surgery.

AIM: Over the past decade, several centralization programs for major pancreatic surgery have been implemented in hospitals with high procedural volumes. Although the impact of this process was altogether positive, also possible negative effects have been evidenced, above all the lack of comprehensive coverage and access to specialized centers. In order to solve these problems, it was proposed the utilization of an outcome-based and not volume-based center selection. For this purpose the choice of an appropriate outcome assessment system is crucial. MATERIAL OF STUDY: We retrospectively reviewed 74 patients undergoing pancreatoduodenectomy. The outcomes were evaluated utilizing the Accordion Severity Classification of Postoperative Complications. RESULTS: The morbidity of 58 % and the mortality of 4 % were comparable with the ones reported in large series utilizing the same classification system. CONCLUSIONS: The Accordion system is an effective method of quality control for pancreatic surgery both in high- and low-volume hospitals.

Comparison between thyroidectomy and hemithyroidectomy in treatment of single thyroid nodules identified as indeterminate follicular lesions by fine-needle aspiration cytology.

AIM: The objective of this study is to determine the optimal surgical approach for patients undergoing thyroid operation for indeterminate follicular lesions diagnosed by cytology and to evaluate the long-term outcome of patients treated by hemi or total thyroidectomy for these lesions. MATERIAL OF STUDY: From January 2000 to January 2010, 98 patients having a solitary thyroid nodule with a cytological diagnosis of "indeterminate follicular lesion" were selected retrospectively. RESULTS: There were 81 women and 17 men with a mean age of 56 years (range: 28-83). Hemithyroidectomy (HT) was performed in 57 patients (58%) and a Total thyroidectomy (TT) in 41 (42%). Postoperative morbidity was 3.50% in patients who underwent HT and 9.75% in those who underwent TT At the histological analysis 16 (16.32%) patients had a malignant lesion. DISCUSSION: HT was considered adequate treatment for 51 patients (89.48%) while in 6 patients (10.52%) has been necessary a completion thyroidectomy. Total thyroidectomy was not associated with clinically significant additive morbidity No permanent hypoparathyroidism and no definitive recurrent nerve palsies were observed in either group. Postoperative thyroid hormone replacement was required in 40.35% of lobectomy patients. Overall, in the indeterminate follicular lesions patient population, 57 hemithyroidectomies were performed and no further operation was required in about 90% of patients. CONCLUSIONS: Considering the high rate in which HT represents the adequate treatment, and the low rate of re-operation morbidity, HT seems to be the preferable initial surgical approach for indeterminate follicular lesions. Long-term ultrasonographic follow-up seems advisable.

Minimally invasive video-assisted thyroidectomy compared with conventional thyroidectomy in a general surgery department.

BACKGROUND: We retrospectively evaluated a series of patients who underwent minimally invasive video-assisted thyroidectomy (MIVAT) to define its advantages or disadvantages. METHODS: Between May 2005 and March 2008, 68 patients underwent MIVAT. Sixty-nine patients who underwent conventional thyroidectomy (CT) during the period before the introduction of the MIVAT technique in our department-chosen with the same inclusion criteria used for MIVAT-served as matched controls. The eligibility criteria for both groups was thyroid nodules < or = 35 mm, thyroid volume < 25 ml, no thyroiditis, and no previous surgery. RESULTS: Forty-five MIVAT and 43 CT patients underwent hemithyroidectomy. Twenty-three MIVAT and 26 CT patients underwent total thyroidectomy. No differences were found in terms of complications, operative time, and radicality of the procedure. Patients who underwent MIVAT experienced significantly less pain, better cosmetic results, and shorter hospital stay than patients who underwent conventional surgery CONCLUSION: The MIVAT technique, in selected patients, seems to be a valid option for thyroidectomy and even preferable to conventional surgery because of its significant advantages, especially in terms of cosmetic results, postoperative pain, and postoperative recovery.

"Minimally invasive video-assisted thyroidectomy. Initial experience in a general surgery department".

BACKGROUND AND AIMS: The aim of this study is to analyze our preliminary results from minimally invasive video-assisted thyroidectomy (MIVAT) and demonstrate the feasibility of MIVAT also in non-referral centers. MATERIALS AND METHODS: We report our initial experience based on a series of 47 patients selected for MIVAT at General Surgery Department of University of Trieste during a period from May 2005 to February 2007. The eligibility criteria were rigorously observed. Age, goiter volume, major diameter of the dominant nodule, operative times, pathologic findings, postoperative pain, length of hospital stay, cosmetic results, and complications were retrospectively analyzed. RESULTS: Thyroid lobectomy was successfully accomplished in 33 cases, total thyroidectomy in 14. Conversion to standard cervicotomy was required in three patients (6%). Mean operative time of lobectomy was 82.6 min and 118.7 for total thyroidectomy. Postoperative complications included 11 (23.4%) transient hypocalcemias, 2 (4.2%) hematomas, and 2 (4.2%) temporary laryngeal nerve palsies. None-recurrent nerve palsies was observed. The cosmetic result was excellent in most cases. CONCLUSIONS: Our experience demonstrates that MIVAT, after adequate training, is feasible and safe, with results comparable to conventional thyroidectomy, also in a General Surgery Department, from a dedicated team, with a sufficient and specific activity volume.

Circumferential mucosal dissection and esophageal perforation in a patient with eosinophilic esophagitis.

A young man with a previous history of episodes of mild solid food dysphagia was admitted with a total dysphagia. The esophagogastroduodenoscopy (EGDS) showed an extensive disruption of mucosal layer with a cul-de-sac in the lower part of the esophagus. Soon after the procedure, the patient suffered from an acute chest pain and subsequent CT scan demonstrated an intramural circumferential dissection of thoracic esophagus, and a mediastinal emphysema. An emergency right thoracotomy was performed, followed by a total esophagectomy with esophagogastroplasty and jejunostomy. The histopathology confirmed that mucosal and submucosal layers were circumferentially detached from muscular wall and showed an eosinophilic infiltration of the whole organ with necrosis and erosions of mucosal, submucosal and muscular layers. The diagnosis was esophageal perforation in eosinophilic esophagitis.

Autotransplantation of thyroid tissue in rats. An experimental study.

BACKGROUND: The aim of this study is to demonstrate the functional capacity of thyroid autografts after total thyroidectomy in a rat model. MATERIALS AND METHODS: 60 rats were divided into 6 groups of 10 rats each. Thyroid gland was cut into 0.5 mm pieces and was inserted intramuscularly into the left rectus abdominis muscle at different time intervals following total thyroidectomy. The animals were observed for 30 days. Blood samples were collected weekly for TSH, FT3 and FT4 measurements. This study was conducted in strict accordance with the provisions of the law concerning test procedures on animals, as per Legislative Decree n.116/92. RESULTS: Autologous transplantations were successful in 70% of the cases. Histopathological findings showed normal thyroid architecture. It was observed that thyroid function recovered was more rapidly if the implants were performed immediately after thyroidectomy than in implants performed at a later time. These results could be due to the thyroid tissue preserving procedure used which may have led to reduce the restored thyroid function in the groups of animals where the implantation was not immediate. CONCLUSIONS: Ectopically transplanted thyroid tissue is able to survive and recover its function completely if maintained vital in an adequate preserving medium.

Pancreatic Injury Following Blunt Abdominal Trauma during a Soccer Game.

UNLABELLED: This article reports a case of unusual pancreatic trauma, underestimated initially and treated surgically at a later stage. A 26-year-old man presented with an abdominal trauma sustained during a soccer game. The patient arrived 24 hours after the trauma with abdominal pain associated to vomiting and intestinal occlusion. Laboratory tests revealed elevated serum amylase levels. An abdominal computed tomography (CT) scan showed a pancreatic parenchymal dishomogeneity at the passage between body and tail, highly suspicious for pancreatic full thickness laceration. Magnetic resonance pancreatography (MRP) demonstrated possible duct involvement. The patient was urgently submitted to distal pancreatectomy with splenectomy. This case demonstrates a rare mechanism of injury and the potential importance of serial CT scans in the diagnosis, grading, and management of isolated pancreatic injury. KEYWORDS: pancreatic injury; blunt abdominal trauma; pancreas; duct disruption.

[Adhesive small bowel occlusion: a clinical and therapeutic study of 163 consecutive patients]. / L'occlusione intestinale da aderenze. Valutazioni cliniche e terapeutiche su 163 casi consecutivi.

The aim of this retrospective study is to evaluate the immediate and late outcomes of the surgical and conservative treatment of adhesive small bowel obstruction. A series of 163 consecutive patients affected by adhesive occlusion were analysed. 63 patients were submitted to emergency surgery and 100 to conservative treatment; 15 of these ones were operated on because they did not improve or deteriorated. The in-hospital mortality and morbidity, the length of the ileus, the time required for the operation, the length of the recovery, and the late results after a median follow-up of 3.6 years (range: 1-6 years) are reported. The overall mortality was 3.26% and there was no significant difference (p = 0.764) between the treatment modalities. The patients submitted to conservative therapy had a lower morbidity, shorter length of the ileus and shorter hospital stay and a better outcome at follow-up. In the surgical group, the patients submitted to emergency surgery had a lower mortality, a shorter ileus and shorter hospital stay than the patients submitted to delayed surgery. Conservative treatment of adhesive occlusions should be opted for when the indications are correct (no intestinal ischaemia, no occlusion by a bridle). In doubtful cases, the patient should be submitted to emergency surgery to avoid the risks of surgical delay.

Primary bilateral adrenal non-Hodgkin's Burkitt-like lymphoma: a rare cause of primary adrenal insufficiency. Case report and literature review.

AIMS AND BACKGROUND: Primary bilateral adrenal non-Hodgkin's lymphoma is an extremely rare entity. Only 44 cases have been reported in the literature. The most common presenting symptoms are abdominal pain, fever, asthenia, constipation, weight loss or typical symptoms of adrenal insufficiency, hypertension, darkening of skin, orthostatic hypotension or an addisonian crisis. METHODS: The case is presented of a 57-year-old man suffering from primary bilateral adrenal lymphoma with symptoms of adrenal insufficiency syndrome associated with bilateral, stabbing lumbar pain and a palpable mass on the left side. Laboratory tests revealed a considerable increase in lactate dehydrogenase levels, adrenal insufficiency, and high corticotropin levels. RESULTS: Abdominal CT scan showed two large adrenal masses. A CT-guided fine needle aspiration biopsy revealed a large B-cell non-Hodgkin's lymphoma. Combination chemotherapy according to the CHOP protocol with cyclophosphamide, doxorubicin, vincristine and prednisolone was initiated, which caused a slight reduction in size of the two adrenal masses. The patient underwent a bilateral adrenalectomy with almost complete excision of the tumors. Replacement therapy with cortisone acetate was initiated postoperatively. Adjuvant combination chemotherapy according to the CHOP protocol was started but renal failure gradually emerged and the treatment could not be completed. The patient died seven months after surgery due to acute bronchial pneumonia and progression of disease. CONCLUSIONS: Primary bilateral adrenal non-Hodgkin's lymphoma mainly affects adult men. Diagnosis is based on histological examination. Whether associated or not with radiotherapy, chemotherapy is the most recommended treatment. Surgery, where possible, seems to lead to an increase in survival rates, but it is not possible to draw any definite conclusions on its effectiveness as yet.

Gastric wall necrosis from organo-axial volvulus as a late complication of laparoscopic gastric banding.

We present a case of massive gastric wall necrosis associated with volvulus of the stomach occurring 17 months after laparoscopic gastric banding. The 19- year-old female was admitted to our hospital with acute abdominal pain with rapid deterioration from massive necrosis of a distended stomach which perforated distal to the gastric band, accompanied by splenic infarction. Total gastrectomy and spenectomy were required. We present this very rare complication which should be recognized and treated early, so that a less drastic operation is possible.

Sentinel lymph node mapping in the management of colorectal cancer: preliminary report.

AIM AND BACKGROUND: The problem of understaging the lymph node status in colorectal cancer because of missed micrometastases led authors to investigate the role of sentinel node (SN) mapping also in colorectal malignancies. The aim of this study was to evaluate the feasibility of the technique and to correlate the results with some characteristics of the primary tumor. METHODS: Sentinel lymph node mapping was performed in 23 patients who underwent a standard lymphadenectomy for colorectal cancer. The vital dye Patent Blue had been injected into the peritumoral subserosa in vivo in 17 cases and ex vivo in seven, including one case where the in vivo method did not allow to identify the sentinel node. The nodes that took up the dye were removed and analyzed with standard hematoxylineosin staining in serial sections. Immunohistochemistry (AE1-AE3 cytokeratin markers) was performed in hematoxylineosin-negative nodes. SN status was related to the status of the other lymph nodes in the surgical specimen analyzed with the standard technique and to the following characteristics of the primary tumor: stage, grade and diameter. RESULTS: The in vivo technique allowed to identify the SN in 16/17 cases (94.1%), the ex vivo technique in 7/7. A total of 336 lymph nodes dissected from the surgical specimens was analyzed, with an average of 14.6 nodes per patient (range, 7-35). Of these nodes 58 were SNs, with an average of 2.5 nodes per patient (range, 1-8). In the 19 cases where the SN was tumor negative, the non-SNs were also negative (specificity: 100%), whereas in the four cases where the non-SNs were positive, in two cases the SN was positive and in two cases of pT3 rectal carcinoma the SN was negative (sensitivity: 50%). Immunohistochemistry did not modify the negative results of the standard hematoxylin-eosin evaluation. CONCLUSIONS: The method used to identify the SN using vital dye proved to be easy to use both in vivo and ex vivo and allowed to identify the SN in all cases. The preliminary results indicate that there is a risk of false negative findings and therefore further studies are required to improve the sensitivity and the specificity of the technique and to evaluate the role of SN mapping in colorectal cancer management.

[Prognostic importance of preoperative CEA in patients with colorectal cancer]. / Importanza prognostica del CEA preoperatorio nel paziente con cancro colorettale.

Carcinoembryonic antigen is an acid glycoprotein, the levels of which may increase in patients with colorectal carcinoma. The prognostic significance of preoperative carcinoembryonic antigen levels and their relationship to other risk factors are still debatable issues. Among 512 patients operated on for colorectal cancer, whose preoperative carcinoembryonic antigen concentrations were evaluated, linear correlations were established between carcinoembryonic antigen overexpression and carcinoma staging, diameter and grading, though these were not statistically significant. Moreover, metastatic cancers were significantly more frequent in patients with increased plasma concentrations of the marker (> 60 ng/ml). There were no correlations between increased carcinoembryonic antigen levels and age, ploidy, or site and shape of the cancers. As regards survival, patients with normal preoperative carcinoembryonic antigen levels had a better prognosis in terms both of lower local recurrence rates and long- term survival. In addition. In Dukes stages B and C elevation of carcinoembryonic antigen above the cut-off point can be considered a significant prognostic factor capable of identifying a group of patients at high risk who may be candidates for aggressive adjuvant therapies and follow-up. The findings of this study suggest that preoperative carcinoembryonic antigen levels are of prognostic importance in relation both to cancer staging and to long-term survival, which may have significant clinical applications.

[Treatment of adenocarcinoma of the duodenum: presentation of 4 clinical cases and review of the literature]. / Trattamento dell'adenocarcinoma del duodeno: presentazione di quattro casi clinici e revisione della letteratura.

The Authors comment on the difficulty of diagnosing and treating duodenal tumours. The most appropriate indications and extent of resection of these neoplasms are discussed. The Authors report 4 cases of primitive adenocarcinoma of the duodenum treated by pancreaticoduodenectomy (2 cases), segmental resection (1 case) and palliative surgery (1 case) for the presence of omental and lymph-node metastases. Survival was 18 and 14 months in the patients who underwent pancreaticoduodenectomy and 9 months for the patient receiving palliative treatment; the patient who underwent segmental resection is still alive and healthy after 12 months. The Authors point out that adenocarcinoma of the duodenum is an uncommon neoplasm and stress the difficulty encountered in establishing an accurate diagnosis and appropriate surgical management. Better results can be obtained only with an early diagnosis. Chemotherapy and radiotherapy do not significantly improve survival.